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Understanding Community Based Nurse Delegation
2019
Presented by: Nurse Delegation Program Managers
1
Welcome• House keeping notes…
• Introductions
• Thank you for coming
2
Agenda• History of Nurse Delegation
• ND and the Nursing Process
• Forms and Documentation
• Contracting with DSHS
• Billing
• Responsibilities
• Program Evaluation
3
Nurse Delegation Program Managers
Nurses who contract with Aging and Long Term Supports Administers (ALTSA) are supported by:
HCS Marlo Moss RN360-725-2450
DDADoris Barret, RN360-407-1504
4
5
PurposeThis training is:
• Required for all Registered Nurses (RN’s) who would like to contract with DSHS and be paid for Nurse Delegation services
• Offered for RN’s who wish to delegate in other circumstances
• Intended to clarify rules for community based Nurse Delegation Today’s training is not a certification course
6
Important to Know
Attendees will earn seven (7) contact hours of continued education hours:
• To receive full credit for the course
– The attendee must:
• Sign the attendance sheet
• Stay for the entire training
• Complete the evaluation form
7
Knowledge Check
Pre-Work
1. What do you know about Community Based Nurse Delegation?
2. What do you hope to take away from today?
3. Parking Lot questions.
8
Did You Know?Common confusion…
Community Based Nurse Delegation- Describes certain nursing tasks which can be taught to long term care workers under a certain set of rules and circumstances.The rules apply only to community-based settings. The rules for Community Based Nurse Delegation are defined within the Nurse Practice Act
Accountability:– RN is responsible for delegating the nursing task– LTCW is responsible for performing the nursing task as instructed
• Based on written instructions
WAC 246-840-910 thru 970
9
Laws & Rules
What laws and rules govern the program?
Revised Code of Washington (RCW) is the law of Washington State
18.79A.260(3)(e)
Washington Administrative Code (WAC) are the rules of Washington State
246-840-910 thru 970
10
Nurse Delegation Impact
Give me the facts!
• The Nurse Delegation program serves approximately 8,600 clients
• The average cost is $186 per month/client
What do you think is the average cost for a Skilled Nursing Facility per month?
11
Who’s Involved
Who's involved with community based nurse delegation
• Client
• Long Term Care Worker (LTCW)
• Registered Nurse (RN)
• Case Manager (CM)/ Case Resource Manager (CRM-DDA)
• Program Manager (PM)
12
Long Term Care Worker TypesNursing Assistant-Registered (NAR)
Home Care Aide-Certified(HCA-C)
Nursing Assistant-Certified (NAC)
• Registered through DOH• $65 registration fee to DOH• Take 7 hour HIV/AIDS
course• No CE requirement • Must be renewed annually
on birthday
• Completes 75 hours of training
• Certified through DOH• $85 application fee to DOH• Take 4 hour HIV/AIDS
course• 12 hours of CE due each
year• Must be renewed annual
on birthday
• Completes 85 hours of training (7 hour HIV/AIDS included)
• Certified through DOH• $65 application fee to DOH• No CE requirements• Must be renewed annual
on birthday
13
Key Takeaways
Purpose of Nurse Delegation rules
• Rules create a consistent standard of practice
• Support the authority of the RN to make independent and professional decisions
• Enhance client choices
• Protect the public in community-based and in-home settings
14
Program Description
The RN will:
• Assess a client to determine stability and predictability
• Teach the long term care work the nursing task
• Evaluate the performance of the long term care worker
• Provide ongoing supervision of the client’s condition
• Provide ongoing supervision and evaluation of the long term care workers performance of the nursing task
15
Client Type
Who do the rules apply to?
• Clients receiving services in their private homes
• Clients receiving services in Community Residential Settings (SL, GTH, CH)
• Clients receiving services in Adult Family Homes (AFH)
• Clients receiving services in Assisted Living Facilities (ALF)– Formerly known as Boarding Homes
16
Nurse Delegation History1996-97 • Nurse Delegation Rules established through DOH
• Task list created• Three settings identified
• Assisted Living (AL)• Adult Family Home (AFH)• Supported Living (SL)
2000 • Task list eliminated• In home setting added to approved settings
2009 • Law change to include insulin injects and blood glucose monitoring as delegatable tasks
• Prohibited list created
2017 • Rule clarification to include non-insulin injections, used to treat DM as delegatable tasks• Examples include: Byetta, Victoza, Toujeo
2018 • Collaborate with Nursing Commission and stakeholders to expand nurse delegation services:• INR testing• Other subcutaneous injects• Define nurses role in medical marijuana “administration”• Epinephrine injections 17
Nurse Delegation
Client Type
DDA LTC Other
18
The Targeted Population
Who are long term care (LTC) clients?
• Client 18 years or older
• Often times referred to as “aging” clients
• Live in a community- based setting
• Have case managers who work for Home and Community Services (HCS) or an Area Agency on Aging (AAA) office.
19
The Targeted Population Cont.
Who are developmental disability (DD) clients?
• Diagnosed prior to the age of 18• May be an adult or child• Referred to as “developmentally disabled”• Live in a community-based setting• Have case resource managers through Developmentally
Disabled Administration (DDA)• Referrals managed through a regional nurse delegation
coordinator
20
Nurse Delegation
DDA Coordinators:
Region Name Phone number Email address
Region I Gail Blegen-Frost (509) 374-2124 [email protected]
Region II South
Aaron Peterson (253) 372-5850 [email protected]
Region IINorth
Claire Brown-Riker
(206) 568-5773 [email protected]
Region III Brian Wood (253) 725-4282 [email protected]
21
Different Populations
LTC clients DDA clients
• Chronic conditions
• Diabetes
• Arthritis
• Mental health diagnoses
– Alzheimer's
– Dementia
• Congestive heart failure
• Lung disease
• Obesity
WAC 388-106
• Developmental Delays• Autism• Mood disorders
• Bipolar• Major Depressive Disorder
• Schizophrenia• Cerebral Palsy• Epilepsy or seizure disorders
WAC 388-825
22
Additional Variables
So what’s the difference?
DDA client may have:
• Unique or complex medical needs
• Behaviors managed through a positive behavioral support plan (PBSP)
• Frequent medication changes
• High staff turn over
23
Skin Observation Protocol (SOP)
Specific protocol for DSHS clients• Case manager will refer a client to you if:
– Their annual CARE assessment triggers SOP
• RN must follow specific protocol to assess skin• Specific forms• Specific documentation criteria
– Document on triggered referral
• Timeline must be followed without exception.
24
Skin Observation Protocol (SOP) Cont.
Skin Observation Protocol (SOP)HCS DDA
Referral sent by CM Referral sent by CM
RN has 48 hours to accept or deny referral
RN has 48 hours to accept ordeny referral
5 days to contact client, assess client, document clients skin
assessment, and return documentation to the CM
5 days to contact client, assessclient, document clients skin
assessment, and return documentation to the CM
If the client can not be assessed after two attempts or
the client declines the assessment APS or CPS and
the CM must be notified.25
Skin Observation Protocol (SOP) cont.
Forms to be used when SOP is triggered:
• Nursing Service Referral:– HCS
– DDA
• Basic Skin Assessment
• Pressure Ulcer Assessment– Only complete if there is a pressure injury
• Complete a pressure ulcer assessment for each Pressure injury
26
HCS Nursing Service Referral Form
HCS Nursing
Service
Referral form
(13-776)
27
DDA Nursing Service Referral Form
DDA Nursing
Service
Referral form
(13-911)
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Basic Skin Assessment Form
Basic Skin
Assessment
(13-780)
Page 1
29
Basic Skin Assessment Form Cont.Basic Skin
Assessment
(13-780)
Page 2
30
Pressure Injury Assessment Form
Pressure injury
Assessment
Form
(13-783)
31
Nurse Delegation
Skin Observation Protocol (SOP)
Forms and Power Point can be found on ND website or:
https://www.dshs.wa.gov/altsa/residential-care-services/skin-observation-protocol-sop-resources
32
In SummaryRewind…
• The rules for Community Based Nurse Delegation are defined in the Nurse Practice Act.
• Any RN in the state of Washington can delegate• There is no certification course to delegate in the state of
Washington• Only contracted RN’s with DSHS may receive a referral and be paid
for delegated services for Medicaid clients• The assessed client must be stable and predictable for delegation• The LTCW’s could not perform the nursing tasks without the
supervisor and evaluation of the RN delegating
33
Nurse Delegation
34
Trusted Process
Nurse Delegation is based on the Nursing Process:
• Assess
• Plan
• Implement
• Evaluate
35
HCS Settings
Approved HCS Settings:
Adult Family Home (AFH) Assisted Living Facility(ALF)
In-Home
• 2-6 clients• No nurse required• Regulated by RCS. • Contracted RND paid to
delegate to clients.
• 6 or greater clients• Often times a nurse on
staff during the week. • Regulated by RCS• Contracted nurses are
NOT paid to provide delegation in ALF.
• Clients live in their private homes.
• May be cared for by an IP or AP
• No oversight, unless agency provider
• Contracted RND paid to delegate to client.
36
DDA Settings
Approved DDA Settings:
Supported Living Group Training Homes Companion Home
• Clients may live in their own home, or share a home with up to three others
• Clients are cared for by a state contracted agency
• No nurse required• Contracted RND paid to
delegate to clients.
• Group settings, clients may live in a facility with which serves two or more adults.
• Clients are cared for by facility staff.
• No nurse is required• Contracted RND paid to
delegate to clients.
• Clients reside in theirhome
• Clients are cared for through an agency
• No nurse is required• Contracted RND paid to
delegation to clients
37
Where We Are Not
Delegation does not occur in the following settings:
• Hospitals
• Jails
• Schools
• Other community programs (adult day, senior centers, etc.)
38
Assess
• Setting
• Client
• Nursing Task
• Long term care workers (LTCW’s)
39
Assess Cont.
Assess
Assess the client:
• Full system- head to toe assessment
– Completed within 3 working days of accepting the referral
• Is the clients condition stable and predictable
40
Assess Cont.
Not a standardized form
41
Assess Cont.Assess
What does stable and predictable mean?• The RN determines the clients clinical and behavioral status is non-
fluctuating and consistent.• The client does not require frequent nursing presence• The client does not require frequent evaluation by an RN
Client’s with terminal conditions and those who are on sliding scale insulin are stable and predictable
WAC 246-840-920 (15)
42
Assess Cont.Assess
Assess the nursing task to be delegated:• Does the nursing task fall within your skill set?• Is the nursing task on the prohibited list• Do you need additional assistance to determine delegation
– Consult the decision tree• WAC 246-840-940
• If task determined for delegation is different from the original request, discuss findings with the referring case manager on page two of the referral form.
43
Assess Cont.
Assess Prohibited nursing tasks:
• Sterile Procedures or processes• Injectable medications
– Except insulin and non-insulin injections for DM
• Central line of IV maintenance• Acts that require nursing judgement
44
Assess Cont.Assess
Examples of nursing tasks
45
Assess Cont. Assess
Assess the LTCW:• Does the LTCW have the appropriate training and credentials to
perform the nursing task• Assess the competency of the LTCW performing the nursing task• Identify additional training needs for the LTCW to properly and
safely perform the nursing task• Consider language and cultural diversity which may affect
delegation• Is the LTCW willing and able to perform the nursing task
46
Credentials and Training
Credential type, expiration date, and original issue date
Training classes
Exempt LTCW letter of employment verification 47
Does Not ApplyWho’s exempt from the Home Care Aide training?
• NA-R working with a aging client, who worked one day from January 1, 2011-January 6, 2012.– The NAR must provide a letter of employment verification showing dates of employment.
• NA-R working with a DDA client, who worked prior to 2016.– The NA-R must provide a letter of employment verification showing days of employment (the
DDA 32 hour letter will work).
• HCA-C • NA-C• LPN
https://fortress.wa.gov/doh/providercredentialsearch/SearchCriteria.aspx
48
Home Care Aid Training
What’s included in the Home Care Aide training?
75 hours “Home Care Aid” training• 40 hours “basic training”• 30 hours “population specific”
– Mental health– Dementia
• 5 hours orientation and safety
Training must be completed within 200 days of hireWAC 246-980
49
CredentialsAssess HCS LTCW credentials:
NAR HCA-C NACNon-exempt (after 2012)
1. Verify current NAR credential2. Verify 9 hour Nurse
Delegation for Nursing Assistants
3. If delegated insulin, verify 3 hour SFOD
4. Verify completion of 40 hour Basic Training
Exempt (January 1, 2011-January 6, 2012)1. Verify NAR credential2. Verify 9 hour Nurse
Delegation for Nursing Assistants
3. If delegated insulin, verify 3 hour SFOD
4. Verify completion of basic training:
1. FOC2. RFOC
5. Obtain a letter of employment verification-stating dates of employment
1. Verify current HCA-C (HM) credential
2. Verify 9 hour Nurse Delegation for Nursing Assistants
3. If delegated insulin, verify 3 hour SFOD
1. Verify current CNA credential2. Verify 9 hour Nurse
Delegation for Nursing Assistants
3. If delegated insulin, verify 3 hour SFOD
50
CredentialsAssess DDA LTCW credentials:
NAR NAC
Non-exempt (after 2016)1. Verify current NAR credential2. Verify 9 hour Nurse Delegation for
Nursing Assistants3. If delegated insulin, verify 3 hour
SFOD4. Verify completion of 40 hour CORE
Basic Training
Exempt (prior to 2016)1. Verify NAR credential2. Verify 9 hour Nurse Delegation for
Nursing Assistants3. If delegated insulin, verify 3 hour
SFOD4. Verify completion of basic training;
32 hour letter5. Obtain a letter of employment
verification- stating dates of employment
1. Verify current CNA credential2. Verify 9 hour Nurse Delegation for
Nursing Assistants3. If delegated insulin, verify 3 hour
SFOD
51
Consent Process
Consent form (13-678)
52
Assess Cont. Assess
Consent for delegation:
• Discuss the process of delegation with the client or the client’s authorized representative
• Obtain consent– Verbal consent acceptable for first 30 days– Written consent must be obtained after the first 30 days
• Scanned, emailed, or faxed consents are acceptable
• Consent is only needed for initial delegation– No need to get new consent when nursing task changes– Must get new consent if the authorized representative changes
53
Nurse Delegation
Nurse Delegation is based on the Nursing Process:
• Assess
• Plan/Implement
• Evaluate
54
Instructions for Nursing Task
Instructions for Nursing
Task (Form 13-678)
55
Plan/Implement Cont.Plan/Implementation
• Written instructions– Steps to follow when performing nursing task– Predicted outcome– Specific side effects of medications– To whom do LTCW’s report side effects
• Teach LTCW how to perform the nursing task– Based on the written instructions
• Determine caregiver competency– Return demonstration– Verbal description– Record review
• Delegation of a nursing task is at the discretion of the RN assessing and delegating; including the delegation of insulin
56
Plan/Implement Cont.Plan
Instructions:
• Rationale for delegation- the “why”• Specific to the client and their condition
– Not transferable to another client or LTCW
• Clear description or nursing task with step by step instructions• Expected outcomes of delegated nursing task• Possible side effects of medications prescribed
– To whom do LTCW’s report AND when
• How to document the nursing task as completed or omitted.
57
Plan/Implement Cont.Plan
If the nursing task is medication administration:
• Verify what medications are prescribed– Pharmacy list– MAR’s– Conversation with Health Care Provider
• Verify medication changes AND how they were verified• Determine if there is a need to retrain the LTCW on the task• Update delegation paperwork• Update instructions and task sheet
58
Plan/Implement Cont.Plan
Insulin delegation:
• Teach proper usage of insulin• Instruct and demonstrate safe insulin injection technique• Determine competency of LTCW in performing safe insulin administration
– Drawing up the insulin in a syringe– Dialing the dose of insulin on the prefilled syringe– Administering the insulin
• Competency:• Must verify LTCW once a week for the first four weeks of insulin delegation
– The first visit MUST be in person– Each subsequent visit may be verified through
• Observation or demonstration of the task• Verbal communication• Record review
59
Plan/Implement Cont.
Plan
In private homes RN must set up the clients chart, which includes all of the following:
• Nurse delegation forms• Medication orders• Medication administration records (MAR’s)• Credentials for all delegated LTCW’s• Progress notes
60
Plan/Implement Cont.
Plan
In the process of writing your plan, you may need help determining if the nursing task is appropriate for delegation.
Review the decision tree located in the nurse practice act:
WAC 246-840-940
61
Evaluate
Nurse Delegation is based on the Nursing Process:
• Assess
• Plan/Implement
• Evaluate
62
Evaluate Cont.Evaluate
Evaluation of delegation occurs every 90 days.There is no exception
Supervisory visits have 2 components:
1. RN evaluates the client:– Head to toe assessment– Assess client to determine if the client status continues to be “stable and
predictable”– Evaluate the clients response to the delegated nursing task
• Modify tasks if needed• Retrain LTCW’s if needed
63
Evaluate Cont.Evaluate
2. RN evaluates the continued competency of each delegated LTCW:
– Evaluation can be direct or indirect• Observation or demonstration• Record review• Verbal description
– Assess care provided– Documentation submitted in last 90 days– Validate current credentials
64
Evaluate Cont.
Evaluate
Modifications to tasks:
• Update Instructions and Task form• Retrain LTCW’s on updated tasks• Rescind LTCW’s who are no longer delegated to client• Rescind entire caseload• Assumption of caseload
65
Nurse Delegation
Evaluate
Update instructions and task form if:• Nursing task has changed
– Added, discontinued, or modified• RN verifies the new orders with the health care provider• Determines if the task can be delegated• Determines if delegation can occur immediately or if a site visit is
required.– If the task can not be completed immediately the RN initiates and
participates in developing an alternative plan to meet the needs of the client.
66
Evaluate Cont.
Evaluate
RN role in rescinding:
• RN initiates and participates in a safe transition plan with case managers, family member's, and the client.
• RN documents the reason for rescinding and the plan for continuing the nursing task– Who will provide the service in lieu of delegation
67
Evaluate Cont. Evaluate
Rescind delegation if:• Client safety is compromised• Client is no longer stable and predictable• Staff turnover makes delegation difficult• Staff unwilling or unable to perform nursing task
– Task performed incorrectly– Client requests new staff– When any license lapse
• Facility• LTCW• RN
68
Evaluate Cont.Evaluate
Transferring delegation to an assuming RN:• The RN may transfer their case to another RN willing to assume.• The assuming RN will:
– Assess the patient– Assess the nursing tasks as being delegatable and within his/her skill set– Assess the LTCW’s competency– Assess the written instructions and task sheet
Once the care has been assumed, the assuming nurse must document:• Reason for assumption• Notification to client and LTCW’s
69
Evaluate Cont.
Evaluate
• Document the entire Nurse Delegation process
– Including
• Assessment
• Written plan
• Training and credentials
• Verification of competency
70
In SummaryNurse Delegation is based on the Nursing Process
– Assess
– Plan
– Implement
– Evaluate
• Only occurs in four community settings
– Not hospitals, jails, or skilled nursing facilities
• The client must be stable and predictable
• Select nursing tasks can only be delegated
– Prohibited list
– No other list available
• LTCW must have appropriate training and credentials
• There must be an individualized written plan available
71
Summary Cont.
Summary
• Frequency of insulin delegation• How to access the decision tree and when• Evaluation of nurse delegation occurs every 90 days
– Not every 3 months
• When to update nurse delegation documents• When to provide additional training• How to rescind a caseload of LTCW
72
Nurse Delegation
73
Group Activity
Training and Credentials
• Breakout into small groups: 3-5 people• Each group will be assigned a scenario• Take 5-10 minutes to review the scenario,
determine what training and credentials are required and complete the required training and credentials form
• Present your findings to the entire class
74
Activity Role Descriptions
1. A Licensed Practice Nurse who works in an Adult Family Home providing suctioning to a client.
2. An NA-R working for a Supported Living agency, in April of 2012 administering insulin.
3. An NA-C worked in an Adult Family Home in 2013, applying a fentanyl patch.
75
Activity Role Descriptions4. A HCA-C is working in an Assisted Living Facility giving insulin
since. The HCA-C has worked for the same ALF since February of 2012.
5. An NA-R is working with a client in their private home. The client requires insulin injections and wound care daily. The LTCW was hired before January 7, 2012.
6. An NA-R is currently working for a Supported Living agency. The NA-R has been asked to give insulin to a client. The NA-R previously worked for a Home Care Agency in 2011. It is now February 2014.
76
Activity Role Descriptions
7. A NA-R was just hired in an Adult Family Home, on January 15, 2017 and is asked to administer insulin to a client. The NA-R did not work in 2011.
8. A HCA-C is working in an Adult Family Home administering oral medications, it is February of 2013.
9. The NA-R is working in Supported Living, after January 1, 2016, administering insulin injections.
77
Nurse Delegation
78
When To Delegate?
79
Decisions
To delegate or not…
When delegation may not be needed
• Personal care
• Basic first aid
• Self directed care
• Medication assistance
80
Personal Care
Personal care tasks
• Medicated shampoos
• Chlorohexidine mouth rinse
• Topical lotions
• Indwelling catheter care
• Antiembolism stockings (TED)
• Emptying a colostomy bag
• Peri care
• Filing nails
81
Basic First Aid
Basic First Aid
• Applying a bandage to a cut
• Reinforcing a bandage
• Administering epinephrine under the– “Good Samaritan Law”
• RCW 4.24.300
82
Self Directed CareSelf Directed Care
• Nursing care provided to a client who resides in their private home by an Individual Provider (IP).– Only occurs in private homes– Only if an Individual Provider is providing care– Client trains and supervises the Individual Provider on
their completion and competency level– Client must be cognitively aware
• As determined by the case manager in her assessment
– The clients physician must be aware the client is self directing their care
The IP can provide any nursing task an able bodied person could do for themselves.
WAC: 388-825-400RCW: 74.39
83
Medication AssistanceMedication Assistance
• Rules written by the Board of Pharmacy• Describes ways to help an individual take their medications
• Remind• Coach• Open• Pour• Crush• Dissolve• Use of an enabler• Mix with food or liquids (client must be aware the
medication is in the food or liquid)• Medication assistance can be performed by anyone• Client must be in a community setting
WAC 246-888-020
84
Medication Assistance Cont. Medication Assistance
• If medications are crushed or dissolved it must be noted on a physician or pharmacy order
• Examples enablers:– Cups– Bowls– Spools– Straws– Adaptive devices
• Hand over hand is never allowed as an assistance• Client maintains the right to refuse medications at any time.
85
Medication Assistance Cont. Components of Medication Assistance
In order for medication assistance to take place, the client must meet both:
• Functionally ability: able to get the medication to where it needs to go– Medication to mouth– Ointment on back
AND
• Cognitively aware: he/she is receiving medications– Doesn’t need to know the name of the medication– Intended side effect
If client is not functionally able to take medications and cognitively aware he/she is receiving medications, the medication must be administered by a person authorized to do
so.Delegation is appropriate
86
Medication Assistance Cont.
Medication Assistance
Assisted Living Exception Rule:
• Clients who reside in an assisted living facility who are unable to independently self-administer their medications may receive medication assistance as follows:– If the client is physically unable to self-administer medication
they can accurately direct others to do so.
This is not self directed care
87
Medication Assistance Cont.
Medication Assistance
So what is covered under medication assistance?
• Oral medication administration• Topical medication administration• Ophthalmic medication administration• Insulin pen set up• Medications via G-Tubes
88
Nurse Delegation
Medication Assistance
What is not covered under medication assistance:
• Injectable medication
• Intravenous medications
• Oxygen administration
89
Nurse Delegation
Blue Board Exercise
Review nursing takes which may need delegation, may not need delegation, or are
strictly prohibited from delegation
90
Nurse Delegation
91
Forms Review
92
Delegation Forms Review
Review sample chart:FORMS:
• Referral• Consent• Credentials and
verification• Head to toe assessment• Instructions and nursing
task• Nursing visit• PRN• Change in medication or
treatment• Rescinding• Assumption• SOP documents• Billing tracker 93
Nurse DelegationStep by step process for delegation
Forms review
Initial delegation:• Referral
– Case Manager will scan, email, or fax if a state client
• Attached to the referral:– Copy of most recent CARE assessment
• Including behavior support plans
– Release of information– Authorization number – Date of birth
• Assessment of client must be completed within three days from the date of accepting referral. – If unable to meet this deadline, discuss with case manager
94
Nurse Delegation Referral Form
Referral form
(01-212)
Page 1
95
Nurse Delegation Referral Form Cont.
Referral form
(01-212)
Page 2
96
Consent for DelegationConsent for delegation
Obtain client or the clients authorized representative consent for delegation. • Obtain prior to initiating delegation• Verbal consent is good for 30 days
– After 30 days you must have a signed consent form.
• Consent only needs to be gathered one time, at the start of delegation– If the client authorized representative changes– If assuming a case and the new RN wants to explain the delegation
process
97
Consent for Delegation Form
Consent form
(13-678)
98
Credentials and Verification Form
Credentials and verification form
• Check credentials for all delegated LTCW’s• Complete training and credentials form or print
copies of training and credentials• Document verification of all training and
credentials• Verification of exempt LTCW letter of
employment
99
Credentials and Verification Form
Credentials
And
Training
Verification
(10-217)
100
Physical Assessment
Head to Toe Assessment
• Full systems nursing assessment
– Currently no standardized form required
– Must be completed at each supervisory visit
• RN may chart per exception after the initial assessment.
101
Physical Assessment Form
Head to toe
assessment
102
Instructions and Task SheetInstructions and Task Sheet
• Complete instructions and task sheet for each delegated task– Oral medications– Topical medications– Wound care
• List medications delegated– Method of verification
• MD order• MAR review• Pharmacy
• Step by step task analysis to complete nursing task
103
Instructions and Task SheetInstructions and Task Sheet
• Expected side effects• When to notify the RN
– Provide contact information
• When to notify MD– Provide contact information
• When to notify 911
Be specific when giving examples of side effects. Remember, side effects and steps to perform task are specific to the client
104
Instructions and Task Sheet
Instructions
And task
Form
(13-678)
105
Nursing Visit Form
Nursing Visit Form
• The nursing visit form is the most widely used form– Initial assessment– Supervisory (90 day) visits– Change in condition– Change in delegated task– Rescinding of LTCW– Delegation to new LTCW– other
106
Nursing Visit Form
Nurse visit form
(14-484)
107
Supplementary Forms
The following forms are not required, but can be used:
• PRN
• Change in medical orders
• Assumption
• Rescinding
108
PRN Medication Form
There is room for multiple PRN medications to be listed
109
Nurse Delegation
Not an acceptable order due to ranges
110
PRN Medication Form Cont.
Acceptable order for delegation111
Change in Medical Orders Form
• If there is a change in medications mid review cycle• Change in dosage• Addition of short term medication
– 10 day course of antibiotic ointment
• Change in a nursing task
The change in medical orders form is similar to the instructions and task form
112
Change in Medical Orders Form Cont.
Change in
Medications
Or treatment
(13-681)
113
Change in Medical Orders Form Cont
RN can make the decision to delegate immediately or require a site visit
114
Rescinding Form
• Document date rescinded
• Who you rescinded
• Why you rescinded
115
Rescinding Form Cont.
Rescinding
Form
(13-680)
116
Assumption Form
• If you are assuming a case complete the assumption form to verify date assumed
• This is the date you will begin assuming liability
• Document the reason why assumption occurred.
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Assumption Form Cont.
Assumption
Form
(13-678B)
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Additional Billing Tracker
Additional
Billing
tracker
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Nurse Delegation
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Group Activity
Background:
On 11/20/2016 at 10:15am you receive a call from Judy a Case Manager in your local Home and Community Services office, she is looking for a nurse delegator to evaluate a client to determine if delegation is appropriate. He currently has informal support at home however has enlisted the help of three caregivers to help complete his care needs.
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Group Activity Cont.
Break out into groups of 5Take 10 minutes to work through the following scenario.
Answer questions as a group, on slide 111.Be prepared to talk about your response.
Client History:
Alfonso Green a 66 year old male with a history of insulin dependent diabetes, diabetic foot ulcers, hypertension, congestive heart failure, immobility, and rheumatoid arthritis.
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Group Activity Cont.
From ScenarioMedications and Treatments:
• Novolog • Lantus• Lasix• Metoprolol• Methotrexate• Weekly dressing changes to foot ulcers
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Group Activity Cont.
Forms Scenario
Current Caregivers:
• Lisa- CNA (9 hour nurse delegation course completed and 3 special focus on diabetes completed)
• Rachel- NAR completed on Feb. 11th 2010 and has worked at the same long-term care facility since acquiring NAR.
• David HCA-C- (9 hour nurse delegation course completed)
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Group Activity Cont.
• What form and attachments will you need from the case manager before you complete your assessment?
• Is there specific information you need on that form to complete an accurate assessment?
• Are the caregivers prepared for delegation (Use the Credential and Verification form to help you)?
• What do you need to complete and send back to the case manager?• What would your delegation process look like, from start to finish?
– What information do you need– Who would you contact– What forms would you use– At what frequency would you return to Alfonso’s home to assess him and his LTCW’s
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Contracting with DSHS
Contracting with DSHS for Nurse Delegation
RN’s interested in being paid to delegate for Medicaid clients, in the following settings must be contracted:
– Adult Family Homes
– DDA Supported Living
– Private homes
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Contracting with DSHS
What services can I provide with a DSHS contract?
• Nurse Delegation for both DDA and HCS clients
• Skin Observation Protocol for existing clients
• One time skilled nursing task
– For DDA clients ONLY
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Requirements for Contracting with ALTSA
• RN must attend 8 hour Nurse Delegation Orientation• WA state RN license without restrictions• 1 years RN experience or equivalent experience, determined by ND
program managers• Professional liability insurance
– 1 million incident/ 2 million aggregate
• Pass a criminal background check• Have a National Provider Index (NPI) number• Complete a Core Provider Agreement (CPA)• Have a business license
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Contract Requirements
• Resume or letter of interest• Copy of your certificate from this class• Copy of Drivers License• Copy of RN license• Copy of business license• Copy of professional liability insurance• Completed background check• Completed W-9
– Private business owner
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Nurse Delegation Application Process
1. Return completed packet to ND Program
2. ND Program Manager
3. ALTSA Contract Unit
4. CPA to Health Care Authority (HCA)
5. HCA to ALTSA Contracts Unit
6. ALTSA Contract Unit to RN
7. RN to Contracts Unit
8. Contracts Units to RN Program Managers
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What Can I Bill For?
• Assessments
• Documentation
• Collateral contacts
• Travel time
• Billing time
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Payment
• RN delegators must track time billed
• Billed in units
– 1 unit= 15 minutes
– 4 units= 1 hour
• Current rate is $11.33 per unit
– $45.32 an hours
– Rate set by Legislation
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Nurse Delegation
Billing
• HCS clients are authorized:– 36 units per month x 12 months
• DDA clients are authorized:– 100 units per month x 12 month
If additional units are needed RN must complete an “additional unit request form” outlining rationale
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HCS Additional Units Request Form
HCSAddition UnitRequest form(13-893)
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DDA Additional Units Request Form
DDA
Additional
Request Form
(13-903)
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How Do I Bill?
Billing is completed through the Health Care Authority (HCA)
• You must complete a CPA in order to get access to ProviderOne for billing
• Once you have access you will:– Receive a welcome letter via US mail
– Receive your domain and user name via email
– Receive a second email with a temporary password
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Rolodex Sheet
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Group ActivityGroup work:
Billing Scenarios
Use provided scenario to track units used from the initial date of your referral until the time you billed.
This may include:• Conversation regarding referral• Assessment of client• Task analysis• Training caregivers• Returning documentation • Billing
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Activity
Health Care Authority
ProviderOne self study billing:
https://www.hca.wa.gov/billers-providers/providerone/providerone-social-services
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Activity
Billing practice:• Take 5-10 minutes to walk through purple billing scenario
• Complete sample billing chart
– Track units in category (there is no right or wrong category)
– Add units up based on your billing schedule (weekly, every two weeks, monthly…)
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Nurse DelegationOther DSHS Contract
• Community instructor contract – Train LTCW for 9 hour ND for NA– Train LTCW for 3 hour SFOD
• HCS– Contact Training Unit at (360) 725-2548
• DDA – Contact Doris Barret: (360) 407-1504
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Nurse Delegation
Other DSHS Contracts
• Skilled Nursing Waiver Contract– Provide skilled nursing task– Similar to Home Health
• Wound care• Indwelling catheter insertion• Injections
– Contact local Area Agency on Aging (AAA) office
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Nurse Delegation
Other DSHS Contracts
• Private Duty Nursing– Provide 1:1 care
– Client must require four hours of continued nursing services• Vent
• Trach
– Contact Jevahly Wark (360) 725-1737
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Setting Up Your Business
You must market your business and yourself• Contact CM’s• Develop marketing materials
– Business cards– Flyers– Website
• Contact other RN delegators in y our community• Attend quarterly meetings
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Nurse Delegation
Responsibilities
• Contracted RN responsibilities
• Case manager responsibilities
• ND program manager responsibilities
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Contracted RN
• Document when, how, and from who referral was received• If necessary arrange interpreter services with CM• Assess client within 3 working days of receiving the referral• Provide SOP documentation to CM within five days• Return page two of referral to case manager• Notify CM if there is a change in client condition or nursing
task delegated• Notify CM if rescinding or assuming a caseload
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Contracted RN Cont.
• Maintain duplicate copies of all ND files for six years• Send client files to case managers as requested• Send client files to program managers if requested• If client resides in a private home, set up client chart• Teach LTCW how to safely perform the nursing task• Maintain a current RN license, business license, and
liability insurance• Report suspected abuse or neglect
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Case Manager
• Send referral to RN• Send current CARE assessment• Send positive behavior support plan• Send release of information• Authorize payment for 12 months• Communicate changes in client eligibility• If client referred is in their private home, the case
manager will verify LTCW credentials prior to referring
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Program Manager
• Resource for all contracted RN’s• Resource for RN’s in the state of WA• Resource for all CM’s in the state of WA• Provide follow up and investigations on all delegation
complaints, with contracted nurses• Maintain contracted RN records• Contract Monitoring on all contracted RN’s• Train statewide
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Summary of Delegation
• RCW’s and WAC’s are the same for all clients receiving delegation
• Nurse delegation is based on the nursing process
• Communication is key to having a successful business
• Program managers are available for support
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Nurse Delegation
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Program Evaluation
• Complete orientation evaluation
• Submit evaluation to Program Managers for certificate of completion
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Program Managers
Marlo Moss RNHCS
Doris Barret, RN DDA
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